What Does Health Care Decision Mean For Patients?

This is TELL ME MORE from NPR News. I'm Michel Martin. My thanks to Viviana Hurtado for sitting in for me for a couple of days this week. Coming up we'll ask former attorney general Alberto Gonzales what he makes of the fact that the current attorney general Eric Holder has been declared in contempt of Congress. This is the first time that this has happened to a sitting attorney general.

We'll have that conversation in just a few minutes but first we want to talk about that other political blockbuster story out of Washington: the Supreme Court's decision that most of the Affordable Care Act, including the controversial individual mandate, is here to stay.

And, yes, there are political questions swirling around this decision but we are sure most people are also thinking what does this mean to me, whether you're already insured, in need of insurance, or a business owner who provides coverage for employees.

And we know people are asking these questions because these are just some of the questions we got from listeners who wrote to us on Facebook. So to get some answers we're turning now to Mary Agnes Carey. She is a reporter for Kaiser Health News. That's a non-profit news service and we want to emphasize it is not affiliated with the health insurance provider Kaiser Permanente. And she's with us once again in our Washington D.C. studios.

Mary Agnes Carey, welcome back. Thanks for joining us once again.

MARY AGNES CAREY: Thank you.

MARTIN: Now, the centerpiece of the Affordable Care Act is the individual mandate, the requirement that people purchase health insurance. That was upheld by the court. So what now? What do people have to do to comply?

CAREY: Well, they'll have to - by 2014 if you don't have coverage you'll have to get it. There are some exceptions to the mandate. Not a lot, but some. But for most people if you're getting health insurance at work - a lot of folks get it at work - your insurance will continue.

If you don't have it, if you buy it on the individual market, which is like 18 to 20 million people buying it on their own, in 2014 there may be some subsidies you might qualify for based on your income and also there will be exchanges, these marketplaces set up in states to help you buy coverage.

MARTIN: We've got a lot of questions from listeners on Facebook. This is Benjamin Walker. He's a small business owner in Virginia. This is what he wanted to know.

BENJAMIN WALKER: I had a question about the ramification of the decision for small and medium-sized businesses because everyone has a different interpretation of the part of the legislation that will affect you based on your employee or consultant numbers, and based on the state where they're employed. And I wanted to know how I could best prepare for the insurance overhead.

MARTIN: So, Mary Agnes, what do you say?

CAREY: First thing you have to remember is if you have 50 or fewer workers, what I'm about to discuss, some of the penalties that could apply to businesses don't apply to you. So 50 or under, nothing to worry about. Fifty and above, there are some penalties that could apply in the sense of you don't offer health insurance - again, you're at 50 or higher with your employees - and one of your workers gets a subsidy that I just discussed and they go to the health insurance exchange.

As an employer, you could be fined - you take first, your number of employees, you deduct 30 from that and then at that number it's an assessment of $2,000 per fulltime employee. So while there isn't a requirement that businesses offer health insurance - again, 50 and higher - there is this element of law that says if one of your workers gets a subsidy you may have to pay a fee.

MARTIN: Why is that? What's the logic there?

CAREY: I think the logic there is to encourage employers to offer insurance.

MARTIN: OK.

CAREY: And also if your employee goes into the system and gets insurance with the subsidies and on the exchanges, the federal government wants you to help cover that cost.

MARTIN: And here's another question now from Sarah Wildman. She's a freelance journalist and a visiting scholar at the Johns Hopkins School of International Studies here in Washington. She's also a mom. Here's her question.

SARAH WILDMAN: Before I got pregnant we purchased a maternity rider on top of our individual health insurance plan, hoping to come a pregnancy and labor and delivery. We didn't realize that it was capped at $3,000 for the both. Going forward, will normal women's care include maternity and labor and delivery?

MARTIN: What about that? That is a very important question. There's been so much discussion around the contraception mandate; what about labor and delivery?

CAREY: That will no longer be - as of 2014 - it's no longer a preexisting condition. An insurance company couldn't cover something because it's a preexisting condition, and it will be covered labor and delivery. But here's my thought that I would like to convey - that it's going to be an essential benefit. So you'll have coverage but in the exchange there will be different plans, different levels of coverage.

I think you should still look at it to make sure that it fits your needs. I doubt that it would be as low as a $3,000 cap, which barely - I don't think it comes anywhere near to covering delivery.

MARTIN: We've just scratched the surface with some of the questions that we know that people are asking. What is the question that you are most interested in, yourself, Mary Agnes, so that you think most people would be interested in?

CAREY: I think that looking at it, there are penalties on individuals as well if you don't get insurance. For example, in 2014 the penalty is $95 that you would have to pay if you don't enroll in health insurance. And I'm wondering...

MARTIN: Either through your employer or individually.

CAREY: Or individually. Right. So what the thought is - there is this concern that that penalty isn't tough enough and how many people will not get health insurance because the penalty is so low. And how will the subsidies, will they be - now, they're up to 400 percent of the poverty level which are fairly generous, so will that be enough to incentivize people to enroll in health insurance?

And I'm also looking at - this is - again, we talk about stated-based exchanges. There's essential benefits packages, but states have some leeway. How will the exchanges play out? Will you have a lot of insurers participating? Will you really have that competitive tension that the backers of the health law envision, that you'll have all these businesses competing for your marketplace?

MARTIN: You know, the conservative media has been for, really, months now, arguing that doctors are going to leave the field in droves because of this and that employers are going to drop their employees in droves as a result of this. What does your reporting indicate? Is that true? Is there any credence to this?

CAREY: The one thing I hear from physicians - I hear this conversation a lot, for physicians who are maybe in their 50s or a little bit older, they're looking at the health law. They're looking at some of the requirements placed on them for health, from the electronic information, health IT - health information technology, beg your pardon - that they don't know if they want to comply with some of that stuff. And Medicare - there's other requirements in Medicare that are placed on them.

They're wondering about the Medicaid expansion. Medicaid will be expanded to about 17 million people but sometimes the reimbursement for those services isn't as generous as private insurance. And they're looking at this, possibly, in their careers, as a tipping point. Do I hang in there with the federal law?

Do I obey the federal law and continue my solo practice? Do I retire? Do I go work for a hospital and let them worry about the headaches? But there are also, just to balance this out, there's a lot of provisions in the health law to try to get more primary care physicians out there to meet the demand.

MARTIN: So you're saying that a lot of physicians, perhaps, who were kind of winding down, their careers are at a point in their careers where they're thinking about the next phase or the final phase of their careers...

CAREY: Right.

MARTIN: ...may see this as it's just more change than they want to accommodate. So we'll see. So finally, before we let you go, have to ask you about the one provision that was not upheld. The justices ruled that states can opt out of the big expansion of Medicaid called for in the law. Medicaid is the program that pays for care for low income people, not seniors, although the two groups do overlap.

How might this affect kind of the overall, you know, picture?

CAREY: Well, the Medicaid expansion is envisioned at about 17 million people to the Medicaid rolls these are mostly the childless adults that are not covered now. So states have the option. They don't have to take this, these new enrollees. Nor do they have to take the federal money to cover them.

The federal government's picking up 100 percent of the cost for three years, then it goes down to 90 percent. So a lot of people say even though you have some conservative states now saying we're not going to participate in this, who's really going to leave that kind of money on the table?

MARTIN: Well, so there's obviously a lot to talk about. I hope you'll come back and keep us up to date on this very important story. Mary Agnes Carey is a senior correspondent at Kaiser Health News. Once again, that is not affiliated with Kaiser Permanente. It's a non-profit news service. She was here with us in our Washington D.C. studios. Mary Agnes, thanks so much for speaking with us.

CAREY: Thanks for having me. Transcript provided by NPR, Copyright National Public Radio.